The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation Romanian Journal of Anaesthesia and Intensive Care 2014 Vol 21 No 2, 131-133
CASE REPORTS
The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation Alexander Izakson1, Guy Cherniavsky1, Alexey Lazutkin1, Tiberiu Ezri2*
1
Department of Anesthesia Sieff Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel Department of Anesthesia, Wolfson Medical Center, Affiliated to Tel Aviv University, Israel * Outcomes Research Consortium, Cleveland, OH 2
Abstract We report a clinical case of an 128 kg, 53 year old male, who was scheduled for sleeve gastrectomy surgery. Video laryngoscope (GlideScope – Verathron) assisted intubation was attempted. Despite repositioning of the head and neck and external laryngeal manipulations, two attempts to lift the epiglottis were unsuccessful. An i-gel (Intersurgical, Wokingham, Berkshire, United Kingdom) supraglottic device was successfully placed and normal oxygenation and ventilation was established with pressure controlled ventilation. An Aintree intubation catheter (AIC, Cook Medical, USA) pre-loaded onto a pediatric fiberoptic bronchoscope (FOB) was advanced through the i-gel. After fiber optic visualization of the vocal cords, the AIC and FOB were successfully placed into the patient’s trachea. We conclude that the i-gel may not only serve as a substitute for failed tracheal intubation, but is also useful as a conduit for subsequent fiberoptic intubation. Keywords: difficult intubation, i-gel, Aintree intubation catheter, fiber optic bronchoscope, fiber optic intubation Rom J Anaesth Int Care 2014; 21: 131-133
Case description
Introduction The insertion of a supraglottic airway (SGA) and tracheal intubation through it may be indicated in resuscitation or other scenarios whenever conventional laryngoscopy fails. Various SGA devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), C-trach laryngeal mask and the i-gel supraglottic airway. The ‘i-gel’ which has been developed in 2007 has several distinctive features compared to the other supraglottic airways. Adress for correspondence:
Prof. Tiberiu Ezri, MD Department of Anesthesia Wolfson Medical Center Holon 58100, Israel E-mail: [email protected]
We report a case of an 128 kg, 53 year old male, who was scheduled for sleeve gastrectomy surgery. The preoperative airway evaluation revealed a slightly limited mouth opening with an inter incisor gap of nearly 3.5 centimeters. He had a Mallampati – class 3 and showed normal neck movement. His neck circumference was less than 40 cm. Based on that, we decided to induce general anesthesia intravenously with propofol and rocuronium and proceed with a video laryngoscope assisted intubation (method A). Before the induction of general anesthesia the patient was placed in “ramped” intubation position. After induction of anesthesia, bag-mask ventilation proved to be difficult, though normal ventilation and oxygenation was possible using a four-hands (two persons) mask ventilation technique. Due to the limited mouth opening, video laryngoscope (GlideScope – Verathron) assisted intubation was attempted. Laryngoscopy revealed grade 3 Cormack and Lehane view with large epiglottis. Despite repositioning of the head and neck and external laryngeal manipulations, two attempts to lift
132 Izakson et al.
the epiglottis were unsuccessful. At this point, the patient started to desaturate and mask ventilation became more difficult. As a method B and escape scenario, the i-gel size 4 (Intersurgical, Wokingham, Berkshire, United Kingdom) supraglottic device was successfully placed, according to the ASA difficult airway algorithm (9). After the placement of the i-gel, normal oxygenation and ventilation was established. At this stage we decided to continue the case, performing fiberoptic assisted intubation (method C). A 4.7 mm inner diameter (ID) Aintree intubation catheter (AIC, Cook Medical, USA) pre-loaded onto a 3.5 mm pediatric fiber optic bronchoscope (FOB) was advanced through the i-gel, using a fiber optic elbow connector, without discontinuation of mechanical ventilation. After fiber optic visualization of the vocal cords, the AIC and FOB were successfully placed into the patient’s trachea, above the carina. The i-gel and FOB were subsequently removed and an 8 mm ID endotracheal tube was successfully railroaded over AIC into the patient’s trachea. The patient had uneventful surgery and was successfully extubated in a post anesthesia care unit, when he was awake, pain free and cooperative and having normal oxygenation and ventilation.
Discussion To our knowledge, this is the single case report of successful tracheal intubation using i-gel as a conduit for an AIC fiber optic assisted intubation in an adult patient. There are a few case reports of tracheal intubation through i-gel conduit in the pediatric population [1, 2]. In both cases tracheal intubations were performed using a fiber optic bronchoscope directly through an igel conduit without AIC. We are aware of the three manikin studies comparing FOB guided intubation through both the classic laryngeal mask airway (LMA) and the i-gel, via the AIC sheathed over the FOB or directly over the FOB [3-5]. These studies are equivocal in their conclusions. de Lloyd et al. [3] concluded that the i-gel is likely to be a more appropriate conduit than the classic LMA for fiber optic scope guided intubation irrespective of the intubation method used. The results of Michalek’s study showed that, in manikins, fiber optic intubation through both intubating LMA and i-gel is a highly successful technique. Blind intubation through the igel showed a low success rate and should not be attempted [4]. The findings of Ryusuke Ueki et al. study suggest that the AIC is effective in reducing collisions with the tracheal tube and thus will reduce the risk of mechanical injury to the airway [5]. The results of this study also conclude that intubation took longer with the Fastrack-Single Use (FSU), and the
FSU had a higher failure rate than the other supraglottic airway devices for tracheal intubation. The Aintree Intubation Catheter (AIC) (Cook Critical Care, Bloomington, IN, USA) is a semi-rigid hollow catheter that can facilitate bronchoscope-guided tracheal intubation. The device is 56 cm long with an ID of 4.7 mm, which allows the catheter to be preloaded onto a 4.0 mm, or smaller, fiberoptic bronchoscope and leaves the distal 3-10 cm of the bronchoscope unsheathed for ease of manipulation. The AIC allows endotracheal tube (ETT) ID 7.0 mm or greater to be inserted. During tracheal intubation, the AIC is mounted over a bronchoscope and the bronchoscope/ AIC assembly is inserted through the intubating SGA device into the trachea. After the bronchoscope and SGA are withdrawn, an ETT is railroaded over the AIC into the trachea. During this process, the AIC can also be used for ventilation through the use of a removable Rapi-Fit adapter. The i-gel (Intersurgical Ltd, Wokingham, Berkshire, UK) is a SGA device that features a non-inflatable cuff and the possibility to introduce a gastric catheter. Its successful use has been described in randomized controlled studies [6, 7], including studies showing the possibility to intubate through the i-gel [4, 8]. In our case, after routine airway evaluation, traditional approach to intubation was attempted but did not succeed. Thus, an i-gel was inserted according the ASA Difficult Airway Guidelines [9, 10] in order to provide adequate oxygenation and ventilation to the patient. An i-gel allowed stable airway management when ventilation through a mask became difficult. We conclude that the i-gel may not only serve as a substitute for failed tracheal intubation, but is also useful as a conduit for subsequent fiberoptic intubation. One of the greatest advantages of the combination of i-gel with AIC is the possibility to provide oxygenation and ventilation to the patient, using i-gel, and at the same time having an opportunity to perform fiber optic intubation through AIC. As a matter of fact, having AIC which was advanced into the trachea fiber optically guided, provided us a greater margin of safety during the passage of the endotracheal tube over AIC. Financial disclosure and Conflict of interest Nothing to declare
References 1. Gupta R, Gupta R, Wadhawan S, Bhadoria P. Tracheal intubation through i-gel conduit in a child with post-burn contracture. J Anaesthesiol Clin Pharmacol 2012; 28: 397-398 2. Kim YL, Seo DM, Shim KS, Kim EJ, Lee JH, Lee SG, et al. Successful tracheal intubation using fiberoptic bronchoscope via an i-gel supraglottic airway in a pediatric patient with
The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation 133
3.
4.
5.
6.
7.
8.
9.
10.
Goldenhar syndrome – A case report. Korean J Anesthesiol 2013; 65: 61-65 de Lloyd L, Hodzovic I, Voisey S, Wilkes AR, Latto IP. Comparison of fibrescope guided intubation via the classic laryngeal mask airway and i-gel in a manikin. Anaesthesia 2010; 65: 36-43 Michalek P, Donaldson W, Graham C, Hinds JD. A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: a manikin study. Resuscitation 2010; 81: 74-77 Ueki R, Komasawa N, Nishimoto K, Sugi T, Hirose M, Kaminoh Y. Utility of the Aintree Intubation Catheter in fiberoptic tracheal intubation through the three types of intubating supraglottic airways: a manikin simulation study. J Anesth 2014; 28: 363-367 Janakiraman C, Chethan DB, Wilkes AR, Stacey MR, Goodwin N. A randomized crossover trial comparing the i-gel supraglottic airway and classic laryngeal mask airway. Anaesthesia 2009; 64: 674-678 Theiler LG, Kleine-Brueggeney M, Kaiser D, Urwyler N, Luyet C, Vogt A, et al. Crossover comparison of the laryngeal mask supreme and the i-gel in simulated difficult airway scenario in anesthetized patients. Anesthesiology 2009; 111: 55-62 Kleine-Brueggeney M, Theiler L, Urwyler N, Vogt A, Greif R. Randomized trial comparing the i-gel and Magill tracheal tube with the single-use ILMA and ILMA tracheal tube for ?breopticguided intubation in anaesthetized patients with a predicted difficult airway. Br J Anaesth 2011; 107: 251-257 Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269-1277 Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118: 251-270
Utilizarea i-gel ca introductor pentru cateterul Aintree premergător intubaţiei fibroscopice Rezumat Prezentăm cazul clinic al unui bărbat în vârstă de 53 de ani şi de 128 kg, care a fost programat pentru o intervenţie chirurgicală de gastrectomie longitudinală. A fost încercată intubaţia oro-traheală asistată de videolaringoscop (GlideScope – Verathron). În ciuda repoziţionării capului şi gâtului şi a manipulării externe a laringelui, două tentative de ridicare a epiglotei s-au soldat cu eşec. Un dispozitiv supraglotic i-gel (Intersurgical, Wokingham, Berkshire, United Kingdom) a fost aplicat eficient asigurându-se astfel oxigenarea normală şi ventilaţia pacientului în modul pressure-controlled. Un cateter de intubaţie Aintree (AIC, Cook Medical, USA), preîncărcat pe un bronhoscop fibrooptic pediatric (FOB), a fost avansat de-a lungul dispozitivului i-gel. După vizualizarea fibrooptică a corzilor vocale, AIC şi FOB au fost introduse cu succes în trahee, ulterior plasându-se şi sonda de intubaţie. În concluzie, dispozitivul i-gel este util, atât ca substituent în cazul intubaţiei eşuate cât şi ca ghid în vederea unei intubaţii fibrooptice consecutive. Cuvinte cheie: intubaţie dificilă, i-gel, cateter de intubaţie Aintree, bronhoscop fibrooptic, intubaţie fibrooptică
CASE REPORTS
The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation Alexander Izakson1, Guy Cherniavsky1, Alexey Lazutkin1, Tiberiu Ezri2*
1
Department of Anesthesia Sieff Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel Department of Anesthesia, Wolfson Medical Center, Affiliated to Tel Aviv University, Israel * Outcomes Research Consortium, Cleveland, OH 2
Abstract We report a clinical case of an 128 kg, 53 year old male, who was scheduled for sleeve gastrectomy surgery. Video laryngoscope (GlideScope – Verathron) assisted intubation was attempted. Despite repositioning of the head and neck and external laryngeal manipulations, two attempts to lift the epiglottis were unsuccessful. An i-gel (Intersurgical, Wokingham, Berkshire, United Kingdom) supraglottic device was successfully placed and normal oxygenation and ventilation was established with pressure controlled ventilation. An Aintree intubation catheter (AIC, Cook Medical, USA) pre-loaded onto a pediatric fiberoptic bronchoscope (FOB) was advanced through the i-gel. After fiber optic visualization of the vocal cords, the AIC and FOB were successfully placed into the patient’s trachea. We conclude that the i-gel may not only serve as a substitute for failed tracheal intubation, but is also useful as a conduit for subsequent fiberoptic intubation. Keywords: difficult intubation, i-gel, Aintree intubation catheter, fiber optic bronchoscope, fiber optic intubation Rom J Anaesth Int Care 2014; 21: 131-133
Case description
Introduction The insertion of a supraglottic airway (SGA) and tracheal intubation through it may be indicated in resuscitation or other scenarios whenever conventional laryngoscopy fails. Various SGA devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), C-trach laryngeal mask and the i-gel supraglottic airway. The ‘i-gel’ which has been developed in 2007 has several distinctive features compared to the other supraglottic airways. Adress for correspondence:
Prof. Tiberiu Ezri, MD Department of Anesthesia Wolfson Medical Center Holon 58100, Israel E-mail: [email protected]
We report a case of an 128 kg, 53 year old male, who was scheduled for sleeve gastrectomy surgery. The preoperative airway evaluation revealed a slightly limited mouth opening with an inter incisor gap of nearly 3.5 centimeters. He had a Mallampati – class 3 and showed normal neck movement. His neck circumference was less than 40 cm. Based on that, we decided to induce general anesthesia intravenously with propofol and rocuronium and proceed with a video laryngoscope assisted intubation (method A). Before the induction of general anesthesia the patient was placed in “ramped” intubation position. After induction of anesthesia, bag-mask ventilation proved to be difficult, though normal ventilation and oxygenation was possible using a four-hands (two persons) mask ventilation technique. Due to the limited mouth opening, video laryngoscope (GlideScope – Verathron) assisted intubation was attempted. Laryngoscopy revealed grade 3 Cormack and Lehane view with large epiglottis. Despite repositioning of the head and neck and external laryngeal manipulations, two attempts to lift
132 Izakson et al.
the epiglottis were unsuccessful. At this point, the patient started to desaturate and mask ventilation became more difficult. As a method B and escape scenario, the i-gel size 4 (Intersurgical, Wokingham, Berkshire, United Kingdom) supraglottic device was successfully placed, according to the ASA difficult airway algorithm (9). After the placement of the i-gel, normal oxygenation and ventilation was established. At this stage we decided to continue the case, performing fiberoptic assisted intubation (method C). A 4.7 mm inner diameter (ID) Aintree intubation catheter (AIC, Cook Medical, USA) pre-loaded onto a 3.5 mm pediatric fiber optic bronchoscope (FOB) was advanced through the i-gel, using a fiber optic elbow connector, without discontinuation of mechanical ventilation. After fiber optic visualization of the vocal cords, the AIC and FOB were successfully placed into the patient’s trachea, above the carina. The i-gel and FOB were subsequently removed and an 8 mm ID endotracheal tube was successfully railroaded over AIC into the patient’s trachea. The patient had uneventful surgery and was successfully extubated in a post anesthesia care unit, when he was awake, pain free and cooperative and having normal oxygenation and ventilation.
Discussion To our knowledge, this is the single case report of successful tracheal intubation using i-gel as a conduit for an AIC fiber optic assisted intubation in an adult patient. There are a few case reports of tracheal intubation through i-gel conduit in the pediatric population [1, 2]. In both cases tracheal intubations were performed using a fiber optic bronchoscope directly through an igel conduit without AIC. We are aware of the three manikin studies comparing FOB guided intubation through both the classic laryngeal mask airway (LMA) and the i-gel, via the AIC sheathed over the FOB or directly over the FOB [3-5]. These studies are equivocal in their conclusions. de Lloyd et al. [3] concluded that the i-gel is likely to be a more appropriate conduit than the classic LMA for fiber optic scope guided intubation irrespective of the intubation method used. The results of Michalek’s study showed that, in manikins, fiber optic intubation through both intubating LMA and i-gel is a highly successful technique. Blind intubation through the igel showed a low success rate and should not be attempted [4]. The findings of Ryusuke Ueki et al. study suggest that the AIC is effective in reducing collisions with the tracheal tube and thus will reduce the risk of mechanical injury to the airway [5]. The results of this study also conclude that intubation took longer with the Fastrack-Single Use (FSU), and the
FSU had a higher failure rate than the other supraglottic airway devices for tracheal intubation. The Aintree Intubation Catheter (AIC) (Cook Critical Care, Bloomington, IN, USA) is a semi-rigid hollow catheter that can facilitate bronchoscope-guided tracheal intubation. The device is 56 cm long with an ID of 4.7 mm, which allows the catheter to be preloaded onto a 4.0 mm, or smaller, fiberoptic bronchoscope and leaves the distal 3-10 cm of the bronchoscope unsheathed for ease of manipulation. The AIC allows endotracheal tube (ETT) ID 7.0 mm or greater to be inserted. During tracheal intubation, the AIC is mounted over a bronchoscope and the bronchoscope/ AIC assembly is inserted through the intubating SGA device into the trachea. After the bronchoscope and SGA are withdrawn, an ETT is railroaded over the AIC into the trachea. During this process, the AIC can also be used for ventilation through the use of a removable Rapi-Fit adapter. The i-gel (Intersurgical Ltd, Wokingham, Berkshire, UK) is a SGA device that features a non-inflatable cuff and the possibility to introduce a gastric catheter. Its successful use has been described in randomized controlled studies [6, 7], including studies showing the possibility to intubate through the i-gel [4, 8]. In our case, after routine airway evaluation, traditional approach to intubation was attempted but did not succeed. Thus, an i-gel was inserted according the ASA Difficult Airway Guidelines [9, 10] in order to provide adequate oxygenation and ventilation to the patient. An i-gel allowed stable airway management when ventilation through a mask became difficult. We conclude that the i-gel may not only serve as a substitute for failed tracheal intubation, but is also useful as a conduit for subsequent fiberoptic intubation. One of the greatest advantages of the combination of i-gel with AIC is the possibility to provide oxygenation and ventilation to the patient, using i-gel, and at the same time having an opportunity to perform fiber optic intubation through AIC. As a matter of fact, having AIC which was advanced into the trachea fiber optically guided, provided us a greater margin of safety during the passage of the endotracheal tube over AIC. Financial disclosure and Conflict of interest Nothing to declare
References 1. Gupta R, Gupta R, Wadhawan S, Bhadoria P. Tracheal intubation through i-gel conduit in a child with post-burn contracture. J Anaesthesiol Clin Pharmacol 2012; 28: 397-398 2. Kim YL, Seo DM, Shim KS, Kim EJ, Lee JH, Lee SG, et al. Successful tracheal intubation using fiberoptic bronchoscope via an i-gel supraglottic airway in a pediatric patient with
The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation 133
3.
4.
5.
6.
7.
8.
9.
10.
Goldenhar syndrome – A case report. Korean J Anesthesiol 2013; 65: 61-65 de Lloyd L, Hodzovic I, Voisey S, Wilkes AR, Latto IP. Comparison of fibrescope guided intubation via the classic laryngeal mask airway and i-gel in a manikin. Anaesthesia 2010; 65: 36-43 Michalek P, Donaldson W, Graham C, Hinds JD. A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: a manikin study. Resuscitation 2010; 81: 74-77 Ueki R, Komasawa N, Nishimoto K, Sugi T, Hirose M, Kaminoh Y. Utility of the Aintree Intubation Catheter in fiberoptic tracheal intubation through the three types of intubating supraglottic airways: a manikin simulation study. J Anesth 2014; 28: 363-367 Janakiraman C, Chethan DB, Wilkes AR, Stacey MR, Goodwin N. A randomized crossover trial comparing the i-gel supraglottic airway and classic laryngeal mask airway. Anaesthesia 2009; 64: 674-678 Theiler LG, Kleine-Brueggeney M, Kaiser D, Urwyler N, Luyet C, Vogt A, et al. Crossover comparison of the laryngeal mask supreme and the i-gel in simulated difficult airway scenario in anesthetized patients. Anesthesiology 2009; 111: 55-62 Kleine-Brueggeney M, Theiler L, Urwyler N, Vogt A, Greif R. Randomized trial comparing the i-gel and Magill tracheal tube with the single-use ILMA and ILMA tracheal tube for ?breopticguided intubation in anaesthetized patients with a predicted difficult airway. Br J Anaesth 2011; 107: 251-257 Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269-1277 Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118: 251-270
Utilizarea i-gel ca introductor pentru cateterul Aintree premergător intubaţiei fibroscopice Rezumat Prezentăm cazul clinic al unui bărbat în vârstă de 53 de ani şi de 128 kg, care a fost programat pentru o intervenţie chirurgicală de gastrectomie longitudinală. A fost încercată intubaţia oro-traheală asistată de videolaringoscop (GlideScope – Verathron). În ciuda repoziţionării capului şi gâtului şi a manipulării externe a laringelui, două tentative de ridicare a epiglotei s-au soldat cu eşec. Un dispozitiv supraglotic i-gel (Intersurgical, Wokingham, Berkshire, United Kingdom) a fost aplicat eficient asigurându-se astfel oxigenarea normală şi ventilaţia pacientului în modul pressure-controlled. Un cateter de intubaţie Aintree (AIC, Cook Medical, USA), preîncărcat pe un bronhoscop fibrooptic pediatric (FOB), a fost avansat de-a lungul dispozitivului i-gel. După vizualizarea fibrooptică a corzilor vocale, AIC şi FOB au fost introduse cu succes în trahee, ulterior plasându-se şi sonda de intubaţie. În concluzie, dispozitivul i-gel este util, atât ca substituent în cazul intubaţiei eşuate cât şi ca ghid în vederea unei intubaţii fibrooptice consecutive. Cuvinte cheie: intubaţie dificilă, i-gel, cateter de intubaţie Aintree, bronhoscop fibrooptic, intubaţie fibrooptică
